Nursing Diagnosis in PRIORITY ORDER???

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    Hi! This is my first time posting and having an actual nursing diagnoses assignment and I keep doubting my answers and just want to know if there is anything I should improve on. I have to do 4-5 psychosocial/medical and learning needs. This is my Ob rotation and I am writing diagnoses for the baby. Then I have to list them in order by PRIORITY (#1-5). Thanks in advance for your comments!

    Psychosocial:

    1) Risk for ineffective airway clearance R/T excess mucus production E/B dyspnea...etc

    2) Risk for altered nutrition less than body requirements R/T possible ineffective feeding pattern E/B failure to gain weight

    3) Risk for hyperthermia R/T increased bundling... E/B increased body temperature greater than 100F

    4) Risk for infection R/T immature immune system E/B respiratory symptoms such as apnea, tachypnea, grunting, or retracting

    5) Risk for diaper rash R/T infrequent diaper changes E/B skin inflammation appears redness, scaling, blisters, or papules

    Learning Needs

    1) Knowledge def R/t ineffective airway clearance E/B pt. statement "I will put the bulb syringe in my baby's nose and then compress to suction"

    2) KD R/T to infant feeding pattern E/B pt. statement "I don't kow what times to feed my baby at"

    3) KD R/T safe sleep E/B pt. statement "My baby has a favorite blanket that I let her sleep with in her crib"

    4) KD R/T car seat safety E/B pt. statement "I will place my baby in the caarseat in the front passenger seat so she is next to me"

    5) KD R/T infant care E/B pt. statement "I don't know who to go to whne I need help, it is only my husband and I"
    Last edit by Joe V on Sep 28, '12 : Reason: spacing
    Joe V likes this.
  2. 17 Comments so far...

  3. 1
    prioritization is done by the patient's most important needs. keep in mind that the care plan is a problem solving process, so each nursing diagnosis is actually a patient problem. you list the problems in the order of which is most important of needing attention first. most instructors suggest prioritizing by maslow's hierarchy of needs. the hierarchy from most important to least important is as follows:
    1. physiological needs (in the following order)
      • the need for oxygen and to breathe
      • the need for food and water
      • the need to eliminate and dispose of bodily wastes
      • the need to control body temperature
      • the need to move
      • the need for rest
      • the need for comfort
    2. safety and security needs (in the following order)
      • safety from physiological threat
      • safety from psychological threat
      • protection
      • continuity
      • stability
      • lack of danger
    3. love and belonging needs
      • affiliation
      • affection
      • intimacy
      • support
      • reassurance
    4. self-esteem needs
      • sense of self-worth
      • self-respect
      • independence
      • dignity
      • privacy
      • self-reliance
    5. self-actualization
      • recognition and realization of potential
      • growth
      • health
      • autonomy

    and ericksons growth and development
    Stage Basic Conflict Important Events Outcome
    Infancy (birth to 18 months) Trust vs. Mistrust Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust.
    Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
    Preschool (3 to 5 years) Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.
    School Age (6 to 11 years) Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
    Adolescence (12 to 18 years) Identity vs. Role Confusion Social Relationships Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.
    Yound Adulthood (19 to 40 years) Intimacy vs. Isolation Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.
    Middle Adulthood (40 to 65 years) Generativity vs. Stagnation Work and Parenthood Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.
    Maturity(65 to death) Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.
    http://psychology.about.com/library/...al_summary.htm
    turnforthenurseRN likes this.
  4. 0
    moved for improved response.
  5. 1
    You always priortize actual problems before 'risk for' ones and to prioritize the actuals you go in ABC order and according to Maslow. Also any 'risk for' ones would NOT have evidence...because if they have evidence of a problem then they DO have that problem. At least that is how I was taught in LPN school and during my RN program.

    For instance, you can be 'risk for infection r/t compromise immune system, inadequte primary defenses (broken skin, traumatized tissue, changes in pH etc), chronic disease, invasive procedures etc...but if you have evidense of infection (increased WBC counts, fever, warmth/swelling/redness/purelent drainage around incision site etc..they you do have an infections...you are no longer at risk for it

    Risk for ineffective airway clearance AEB or EB absent cough, adventitious breath sounds (crackles, wheeze, rhonchi) changes in respiration rate and/or rhythm, cyanosis, diminished breath sounds, dyspena, excessive sputum etc....if you have these defining charateristics then you DO have ineffective airway clearance, you are no longer at risk.

    Does that make sense?
    emlam likes this.
  6. 1
    Thank you very much! Loved the help! My teacher has us use R/T and E/B together.
    Instructions on assignment: Nursing Diagnoses: develop 8 daignoses...Provide etiology (R/T) and evidence (E/B) supporting the diagnosis. Prioritize urgen to non-urgen, actual to potential.

    Restating Maslow's Heirarchy helped to refresh my memory. Thanks again!
    Mani15 likes this.
  7. 1
    Quote from CT Pixie

    Risk for ineffective airway clearance AEB or EB absent cough, adventitious breath sounds (crackles, wheeze, rhonchi) changes in respiration rate and/or rhythm, cyanosis, diminished breath sounds, dyspena, excessive sputum etc....if you have these defining charateristics then you DO have ineffective airway clearance, you are no longer at risk.

    Does that make sense?
    We're taught the same thing...there isn't an AEB for a risk because there is no evidence of something that hasn't happened yet.
    CT Pixie likes this.
  8. 0
    Quote from emlam
    Thank you very much! Loved the help! My teacher has us use R/T and E/B together.
    Instructions on assignment: Nursing Diagnoses: develop 8 daignoses...Provide etiology (R/T) and evidence (E/B) supporting the diagnosis. Prioritize urgen to non-urgen, actual to potential.

    Restating Maslow's Heirarchy helped to refresh my memory. Thanks again!
    I understand that would be the case for actual problems, however as I said the risk for's are just that..a risk..and for that reason would have no E/B.

    If your teacher wants you to use E/B for a "risk for" NANDA, then that's how you should word them. She/he is the one grading you..not me
  9. 0
    I had something typed up, but the wheel kept spinning as if my comment was being posted, so I have no idea if my post will even show up. Thank you Pixie! After emailing back and forth with my teacher, I don't think I had to use R/T and AEB together. So to see if I actually comprehend it now, this is what I got out of my teacher, your help and readings

    * Impaired skin integrity R/T excessive bathing AEB dry, scaly and cracked skin*
    *Hyperthermia R/T increased bundling of blankets and clothing AEB hands and feet are warm to touch*

    Then for 'Risk for'
    Risk for ineffective airway clearance R/T excessive mucus production
    Risk for infection R/T immature immune response
    Risk for suffocation R/T baby sleeping on tummy???

    I sure hope that I'm getting closer at correct my diagnosis :-/
  10. 0
    Looks better to me However, I don't like the hyperthermia AEB. Warm hands and feet don't signify hyperthermia to me. I know newborns hands and feet are generally cooler but as I said warm hands/feet to me don't give me enough to say hyperthermia. What is the baby's temp? Add that to the AEB. You mentioned in the first post "increased body temperature greater than 100F". What is the ACTUAL temp that you got on the baby? Was it axillary? Put that down. Did the baby have a flushed look to its skin overall or just the hands/feet were warm?

    Hyperthermia R/T increased bundling of blankets and clothing AEB axillary temp of XXX.X, flushed skin and hands and feet very warm to touch.
  11. 0
    Ct Pixie and Esme, thank you! I did not understand the Risk for and AEB when I removed the temp > 100F. I swear, my brain hurt so much yesterday when I was trying to figure this out from 10am to 10pm. It only took so long for me to comprehend because I had family visiting from a different state
    Thank you to allnurses.com!


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